NOTICE: Posting schedule is irregular. I hope to get back to a regular schedule as the day-job allows.

Friday, July 8, 2011

Pay Attention! [Full link to blog for email clients.][FT:C44]

Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactive Disorder (ADHD).

I was once asked: "could someone please give me a precise definition of ADD? i've gotten a pretty good impression from various online discussion posts, but i'd like a more accurate explanation."

"Precise is, of course a relative term, but here goes..."

ADD is a condition of the brain that affects the ability of a person to shift and apply the focus of their attention. The popular observation of ADD is the "MTV" or "Sesame Street" kid whose attention cannot be focused for more than 5 minutes on any one thing. This is not entirely true, since many kids under 10 would be hard-pressed to concentrate on a boring task for more than 5 minutes anyway.

The key is to "shift and apply" the attention. ADD individuals may be able to "hyperfocus" and shut out all external stimuli, as long as what they are focusing on holds their interest. If you try to break their attention away and cause them to do something else, they may resist to the point of a temper tantrum (even adults). On the other extreme, if the task at hand is not interesting to them, their minds will skip and flit from subject to subject just like a channel-surfing TV watcher, unable to find anything to stimulate their interest.

Clinically, ADD centers around areas of the brain that affect attention, satisfaction and pleasure. The current thinking in the physiological end of the Neurosciences is that there is too little activity of the attention centers of the brain (including the "reticular activating system" right), and the patient cannot focus. This is a chemical disorder, and can be treated medically. In later ages, the ADD person can adopt "thrill-seeking," "self-destructive," or substance abusive behaviors in the attempt to find the stimulation that will help focus their attention. In children, the temper-tantrums and misbehavior so often associated with ADD may be another form of seeking stimulation from their environment.


  1. simply misbehavior
  2. the result of too much refined sugar (my mother's favorite, circa 1971)
  3. hyperactivity (although there is a combined ADD/hyperactivity disorder termed ADHD.)
  4. depression (although both clinical/biochemical and psychological depression can quite often accompany it.)
  5. unusual
  6. a catchall term for kids that the adults are uncomfortable with
  7. sssociated exclusively with high or low intelligence
A note on #5 above: ADD and ADHD can be reflected in a continuum of behaviors, with 0 as a "normal" person who can shift attention easily, yet will focus on even the most ***boring*** task with no trouble, to 10 as an ADD child who can't finish a sentence without running off to do something else (and changing their mind before they get there). It would be more fair to place a majority of persons in the 2-7 range, with the clinical ADD condition (requiring medication) starting at about 6.

A note on #2 above: There is as yet no good reliable link between diet and ADD. There is some link between lack of protein in the evening meal and insomnia (and hence the bedtime behavior of ADD kids), but there is no justification for holistic or homeopathic cures for ADD. Keep this in mind. Any cure can work for *you* if you believe in it enough. But *your* belief is seldom sufficient for the person standing next to you.

A note on #3, 4 and 7 above: An elementary school principal of my acquaintance once stated "It's not the smart, ADHD kids I worry most about, they can be helped by medication and also in part by enriching the classes and giving them challenging work. I care about them, but I worry most about the true ADD and depressed kids. (NOTE:  ADD - not ADHD - kids are often lethargic or hypoactive.)  They can be so 'out-of-it' not paying attention and yet not making trouble, so that you don't pick up on the problem until it has progressed further than with the other kids. I worry that we can be doing these kids a greater disservice."

Now, I'm not going to tell you how to determine if a child (or parent) has ADD or ADHD. That job is best left to the professional clinicians. BTW, they need to know the patient's history. As has been stated elsewhere, a history of ADD/ADHD symptoms before age 7 is an important indicator.

I've heard parents (including myself) say: "My kid can't have ADD, (s)he can sit for hours watching SpongeBob!" That may or may not be true. What does it take to *break* their attention away from the tube? ADD is almost as often reflected in the inability to *break* attention as it is to focus attention.

ADD is sometimes referred to using the term hyperfocus, the ability to selectively focus attention to the point that *all* distractions short of earthquake, fire and flood can not cause the attention to be broken. In terms of the mechanisms of ADD, the scientists feel that since the patient has an underactive system for regulating attention in the brain, anything that *does* activate the brain will be reinforced and the patient will try to maintain that stimulation as long as possible. Of course with the 7 y.o. child, when you force them away from this stimulation, they'll fight you... kicking, screaming, ... in public, preferably.

Is ADD overdiagnosed? I don't know. Is it better *understood* so that doctors are more apt to correctly diagnose it and treat it accordingly? Definitely.

What about medication? In short, it works. Ask any parent of a well-treated ADD child. It seems paradoxical: in the 60's and 70's we referred to the fact that it was strange that stimulant drugs actually calmed down hyperactive kids. However, the commonly used stimulant, Ritalin (methylphenidate) acts directly on the attention centers of the brain. The effect is similar to the "squelch" on a CB radio (remember those?). By increasing the separation between signal (attention) and noise (distraction), you allow the patient to focus appropriately without resorting to the hyperfocus that causes problems. You really should see my son doing homework these days, or sitting quietly in a department store watching the people.

I've heard complaints from teachers and parents alike that we are:

  1. teaching our children to be drug addicts, 
  2. treating them with *too harsh* a chemical for developing brains, 
  3. teaching them to rely on a crutch rather than learning discipline and self-control. 
As a professional neuroscientist with experience of both physiology and pharmacology, I respond:
  1. Methylphenidate is not addictive in the classical sense. Despite a *superficial* chemical resemblance to cocaine, as well as some reports of a "high" induced by massive doses, methylphenidate has been shown *not* to produce craving or withdrawal even at those massive doses. Methylphenidate will *not* support a "self-administration" behavior in the laboratory -- a well accepted scientific model of the addictiveness of a drug where a lab animal (rat or monkey) or human can "choose" whether and how often to take a drug. 
  2. A 10-year-old's metabolism is *considerably* different than an adult's. In addition, the reaction of a non-ADD adult to Ritalin bears *no* comparison to that of an ADD child. Many of these drugs are *more* harsh to the adult with the altered metabolism that comes with age, alcohol consumption, nicotine consumption, onions, pickles, jalapeno peppers! Also, if your brain does not need the boost to its attention mechanisms, the effects of the drug will be felt elsewhere. 
  3. The goal of medicine as a practice is to improve the quality of life of the individual. If giving an ADD patient Ritalin improves their ability to function in society, shouldn't that be our goal?
..and breaking character for just a moment:  "As a parent I respond: YOU COULD MAKE THE SAME ARGUMENTS ABOUT INSULIN! Would you deny insulin to a diabetic child? Or would you deny a crutch to person with a broken leg? The tool (not a crutch) is there to help us learn to live our lives without also having to fight past an otherwise incapacitating condition."

Now, back to the objective descriptions, and here's where the usage of ADD/ADHD as a plot device comes in:  

ADD can be diagnosed at any age. There are adults with ADD or ADHD. Quite a few medical students have it. Many adults of your acquaintance can probably also confirm it. 

There are typically three groupings: 

  • Children diagnosed with ADD who require Ritalin until their teens. Either their brain chemistry changes or they had milder conditions that allow them to learn coping strategies (sort of like dyslexics learning to read). 
  • Children diagnosed with ADD that require Ritalin well into adulthood. 
  • Adults that were never diagnosed with ADD as children, but find that so much of their behavior fits the descriptions of ADD/ADHD that they can be helped with Ritalin. These individuals might have shown severe ADD symptoms as kids, but their parents resisted medication, or they may have gone undiagnosed. It is less likely that the ADD just *appeared* as they grew older. Others have been known to say "I always thought something must be wrong with me, but I never knew what until now."
ADD can be masked by or show up in conjunction with depression. That was the case with my own son.  Many of the severe issues we faced with his ADHD (diagnosed at age 7) were confounded by increasing moodiness and argumentativeness.  At age 15 the psychiatrist diagnosed depression (although to be fair, there were indications at age 7, but he had just suffered through death of his grandfather, so it was not considered clinical depression at the time).  The addition of antidepressants (and Prozac is still the only antidepressant approved for use in patients under the age of 18!) helped a lot, and by the time he entered college he was completely off of all medications.  It was rough, but he made it - he's self motivated, choosing his career and made Dean's List last semester.

By the way, if you are looking at this in terms of personal application, and not just how to incorporate in a story, have a friendly talk with your family physician. I am in the business of training doctors, and the importance of good doctor-patient communication cannot be stressed enough. If you don't trust your doctor, talk to another doctor. If your doctor doesn't communicate well with you, tell him or her that you don't feel you are getting sufficient information, and *ask* for better communication. If you don't get it, find another one. Start at the personal physician stage, and then go to the specialist: psychologist or psychiatrist. If you can't get a referral, talk to another doctor! (Get the point?) If finances are tight, call the local AMA or medical association, or call a medical school. See if someone will talk to you without the full office visit charges. But most important *!*!* ADD should be diagnosed by a qualified professional in a clinical setting, not over the internet, and not from reading Psychology Today.

O.K., that's the summary. ADD is pretty well defined, and pretty well treated. 

As a final point on writing about ADD and ADHD, keep in mind that some folks can do well without medication, but are so much happier when they have it. From my own experience, I know that my son was quite unhappy to *know* he was getting in trouble and couldn't really control it. He loved to do a lot of different things (reading, composition, soccer, basketball, art) which he didn't do as well without medication (especially writing compositions).  So, if writing a character with ADHD, try to explore some of the consequences of  not taking the medication - fuzzy thinking, lack of attention, inability to complete a project, then compare to the capabilities when on appropriate medications.  Explore different variations:  Perhaps extreme heat or exercise causes the medication to wear off too quickly, or the meds interfere with sleep (they can, if too much is taken too late in the day).  With an appropriate background, you can make the character more "real" to readers who have been there, and done that.

Until next time, don't just take care of your brain - use it and write it with care!

No comments:

Post a Comment

Please add comment - no links, spammers will be banned.